Medium

Available on

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Adoption Medical History Form Mobile App

You are being asked to provide family history information at a time that we know is difficult for you; however, this information may be important at some point in providing medical care for your child. There are many medical conditions that can run in families. We are trying to obtain a complete medical history because your child may need this information in the future. Please use the Adoption Medical History Form mobile app to answer the questions as best as you can. If you have any questions about how to answer anything, please ask your adoption worker for help. Each birth parent should complete a Medical-Genetic Family History Form. A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Adoption Medical History Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    You are being asked to provide family history information at a time that we know is difficult fo...

  • Ico statictext

    This page contains information that is needed for the child’s records.

  • Ico textbox

    Child’s Name:

  • Ico date

    Date of Birth:

  • Ico dropdown

    Birthplace:

  • Ico textbox

    Other

  • Ico multiline

    Provide name and address of birth location as well as the name of the doctor or health worker who...

  • Ico textbox

    Birth Mother’s Name:

  • Ico date

    Date of Birth

  • Ico multiline

    Current Permanent Mailing Address:

  • Ico textbox

    Birth Father’s Name:

  • Ico date

    Date of Birth:

  • Ico multiline

    Current Permanent Mailing Address:

  • Ico textbox

    Case Identification Number:

  • Ico multiline

    Name and Address of Agency involved in the Adoption:

  • Ico textbox

    Agency #

  • Ico date

    Today’s date

  • Ico dropdown

    In what month of your pregnancy did you first see a health care worker?

  • Ico dropdown

    Did you have, or were you exposed to, any of the following in pregnancy?

  • Ico checkbox

    Yes

  • Ico checkbox

    No

  • Ico checkbox

    Don't know

  • Ico integer

    What month in pregnancy

  • Ico multiline

    If yes please explain

  • Ico dropdown

    Did you take any of the following?

  • Ico checkbox

    Yes

  • Ico checkbox

    No

  • Ico checkbox

    Don't know

  • ...and More!

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